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Please print or type. (Form designed for use on elite (12-pitch) typewriter.) Form Approved, OMB No. 2050-0039 <br /> UNIFORM HAZARDOUS 1 . Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number <br /> WASTE MANIFEST C(IIL00101142 538 j. t 9. -- 13 0 (1 4('f8 1 Y60 1006461701 SKS <br /> 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) <br /> ValleyFars Trari4spor't; <br /> Tlp <br /> f! ptA ul" l ke Rd <br /> Ls ' IN <br /> 4 4 FIN CA <br /> Generator's Phone: ' 1'071'&628'-'Qf888 <br /> 6. Transporter 1 Company Name U.S. EPA ID Number <br /> IN ""' `::'h! SYSTEMS INC TXROON6121ft <br /> 7. Transporter 2 Company Name U.S. EPA ID Number <br /> 1ra at_i I_:NVT. R0NMEM "rAL, SVC INC ,, MAD039 ���c,-:�e <br /> 8. Designated Facility Name and Site Address CLEAN HMORS i iaAN :1��(.II . U.S. EPA ID Number <br /> tIMI BE; RRYIT 13A ROAD <br /> SAN v( CISE , I ►1 91151. <br /> Facility's Phone: <br /> ga. 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, FNo <br /> ners 11 . Total 12. Unit <br /> HAI <br /> and Packing Group (if any)) Type Quantity Wt.Nol. 13. Waste Codes <br /> NA•a� 082 , tIt"37; 1=it� iJt US! WASTEa I T01 .11L) , It6�t� 4 0t�t lE1&�'7o Pr' . Cte S � { t' I Ilit�MilJi=1 , L.F.AI = ! PG T I T NO <br /> z 2. <br /> D008 22.3 <br /> w <br /> t9 P„% f- <br /> R 7 <br /> 3. - <br /> MAR `c' 8 20019 <br /> 4 <br /> ENVIRONMENTAL HEALTH <br /> 14, Special Handling Instructions and Additional Information r21J, ;'i,J7 `J99 3!t6t - 2i, tl3 <br /> FRI30 171 <br /> � .. <br /> Ella PII : ,C-iE�h( I" '>' #E1, - `*! 1 �! 4Ci41 _. j "� ' � C�r { ('',. } I / �'F'. `! `(.� :f .� <br /> Tt /. .w nrdf; ! : ' 71 my r,01,J 'rizl } . , ,... ,i I .l I : ; } <br /> 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, <br /> ,mar k2Taniff la Bled/placarded, and are in all respects In proper condition for transport according to applicable international and national governmental regulations. If export shipment and I am the Primary <br /> " Exporter, I certi that the contents of this consignment conform to the terms of the attached EPAAckno%yIedgment of Consentl <br /> I certify that P waste minimizations tefn"ent iden 'fied in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if I am a small quantity g6nerator) is true. <br /> Generator's/Offeroes Printedffyped Na e=- -- Signature y Month Day Year <br /> rINS <br /> J 16, International Shipments <br /> F- ❑ Import to U.S. ❑ Export from U.S. Port of entry/exit: <br /> Z Transporter signature (for exports only): Date leaving U.S.: <br /> E 17. Transporter Acknowledgment of Receipt of Materials _ <br /> Transporter 1 Printed/fype;i•Kfame Signature Month Day Year <br /> Q Transpo P Print /Typed Name 1f�, Signaa�! Month Day ea[, <br /> 111 <br /> 18. Discrepancy <br /> 18a. Discrepancy Indication Space ❑ Quantity ❑ Typej j <br /> ❑ Residue ❑ Partial Rejection Full Rejection � <br /> Manifest Reference Number: <br /> F 18b. Alternate Facility (or Generator) U.S. EPA ID Number <br /> U <br /> Facility's Phone: <br /> UJ 18c. Signature of Alternate Facility (or Generator) Month Day Year <br /> Q <br /> Z <br /> 55 19. Hazardous Waste Report Management Method Codes (Le', codes for hazardous waste treatment, disposal, and recycling systems) <br /> 0 2. <br /> 20, Designated Facility;Owner or Operator: Certification of receipt of.hazardous materials covered.by the manifest except as noted jn'Item 18a <br /> Printed/Ty ed Name/ Signature „ Month Day., Year/Nix NOr <br /> I <br /> EPA Form 8700-22Rev. 3-05 Pre! t_VOVf vious editions are DESIGNATED FACILITY TO GENERATOR <br /> obsolete. , % <br /> ( <br />